General

1. Does each daily note need to address short and long term goals?
2. Can you clarify the physician visit requirement for Medicare Part B beneficiaries please? Is there still a 30 or 60 day requirement?
3. If the therapies or level of care changes, are we required to obtain the physician’s signature?
4. Describe differences between re-certification and re-evaluation. Provide examples.
5. Therapist feels the patient needs additional time, do we need to get a physician’s signature?
6. What if we are treating the patient for one body part and another body part needs treated? Is this a new evaluation or a re-evaluation and are we required to keep separate charts for separate conditions.
7. If the therapist completes the evaluation and determines that no treatment is required, do we need to get the physician’s signature?
8. Can we file a delayed certification if we cannot obtain the physicians signature?
9. Does the progress report count as the re-certification if we obtain a physician signature?
10. Is there a trend or preference for more laymen vs. scientific terminology?
11. If a patient is part of a physician group practice, can another physician from the group certify the plan of care in the absence of the referring physician?
12. Is electronic signature acceptable?

1. Does each daily note need to address short and long term goals?

   The purpose of treatment notes is simply to create a record of all treatments and skilled interventions that are provided and to record the time of the services in order to justify the use of billing codes on the claim. Documentation is required for every treatment day, and every therapy service. The Treatment Note is not required to document the medical necessity or appropriateness of the ongoing therapy services. Documentation of each Treatment shall include the following required elements:  

   • Date of treatment
   • Identification of each specific intervention/modality provided and billed, for both timed and untimed codes
   • Total timed code treatment minutes and total treatment time in minutes
   • Signature and professional identification of the qualified professional who furnished or supervised the services and a list of each person who contributed to that treatment

   Documentation of each Treatment may also include the following optional elements to be mentioned only if the qualified professional recording the note determines they are appropriate and relevant:

   • Patient self-report
   • Adverse reaction to intervention
   • Communication/consultation with other providers (e.g., supervising clinician, attending physician, nurse, another therapist, etc.)
   • Significant, unusual or unexpected changes in clinical status
   • Equipment provided
   • Any additional relevant information the qualified professional finds appropriate.
     (Reference:  CMS Pub 100-02, Ch 15, 220.3, E)

   Date Posted: 04/04/2007, Date Reviewed/Revised: 01/09/2008

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2. Can you clarify the physician visit requirement for Medicare Part B beneficiaries please? Is there still a 30 or 60 day requirement?

   Physicians/NPPs may require that the patient make a visit for an examination if, in the professional’s judgment, the visit is needed prior to certifying the plan.

   Physicians/NPPs should indicate their requirement for visits, preferably on an order preceding the treatment, or on the plan of care. Physicians/NPPs should not sign a certification if they require a visit and a visit was not made. However, Medicare does not require a visit unless the National Coverage Determination (NCD) for a particular treatment requires it (e.g., see Pub. 100-03, §270.1 - Electrical Stimulation (ES) and Electromagnetic Therapy for the Treatment of Wounds). (Reference: CMS Pub. 100-02, Ch. 15, 220.1)

   Date Posted: 04/04/2007, Date Reviewed/Revised: 01/09/2008

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3. If the therapies or level of care changes, are we required to obtain the physician’s signature?

   Procedures (e.g., neuromuscular reeducation) and modalities (e.g., ultrasound) are not goals, but are the means by which long and short term goals are obtained. Changes to procedures and modalities do not require physician signature when they represent adjustments to the plan that result from a normal progression in the patient’s disease or condition. Only when the patient’s condition changes significantly, making revision of long term goals necessary, is a physician’s/NPP’s signature required on the change, (long term goal changes may be accompanied by changes to procedures and modalities). (Reference: CMS Pub 100-02, Ch. 15, 220.1.2 C)

   Date Posted: 04/04/2007, Date Reviewed/Revised: 01/09/2008

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4. Describe differences between re-certification and re-evaluation. Provide examples.

   Re-certification - Payment and coverage conditions require that the plan must be reviewed, dated and signed by a physician/NPP every 30 days (60 days for CORF) to complete the certification requirements in 42CFR 410.61(e), unless delayed certification requirements are met. (Reference: CMS Pub 100-02, Ch. 15, 220.1.3 C)

   Re-evaluation provides additional objective information not included in other documentation. Re-evaluation is separately payable and is periodically indicated during an episode of care when the professional assessment of a clinician indicates a significant improvement or decline or change in the patient's condition or functional status that was not anticipated in the plan of care for that interval. Although some regulations and state practice acts require re-evaluation at specific intervals, for Medicare payment, re-evaluations must meet Medicare coverage guidelines. The decision to provide a re-evaluation shall be made by a clinician.

   Date Posted: 04/04/2007, Date Reviewed/Revised: 01/09/2008

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5. Therapist feels the patient needs additional time, do we need to get a physician’s signature?

   Yes a physician's signature would be needed on recertification requirements.

    

   Date Posted: 04/04/2007, Date Reviewed/Revised: 01/09/2008

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6. What if we are treating the patient for one body part and another body part needs treated? Is this a new evaluation or a re-evaluation and are we required to keep separate charts for separate conditions.

   During the episode, the beneficiary may be treated for more than one condition; including conditions with an onset after the episode has begun. For example, a beneficiary receiving PT for a hip fracture who, after the initial treatment session, develops low back pain would also be treated under a PT plan of care for rehabilitation of low back pain. That plan may be modified from the initial plan, or it may be a separate plan specific to the low back pain, but treatment for both conditions concurrently would be considered the same episode of PT treatment. If that same patient developed a swallowing problem during intubation for the hip surgery, the first day of treatment by the SLP would be a new episode of SLP care. (Reference: CMS Pub 100-02, Ch. 15, 220 A)

   Date Posted: 04/04/2007, Date Reviewed/Revised: 01/09/2008

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7. If the therapist completes the evaluation and determines that no treatment is required, do we need to get the physician’s signature?

   The referral/order of a physician/NPP is the certification that the evaluation is needed and the patient is under the care of a physician. Therefore, when evaluation is the only service, a referral/order and evaluation are the only required documentation. (Reference: CMS Pub 100-02, Ch. 15, 220.3 C)

   Date Posted: 04/04/2007, Date Reviewed/Revised: 01/05/2008

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8. Can we file a delayed certification if we cannot obtain the physicians signature?

   Yes.  Evidence of diligence in providing the plan to the physician may be considered by the contractor during review in the event of a delayed certification. Delayed certifications should include any evidence the provider or supplier considers necessary to justify the delay. For example, a certification may be delayed because the physician did not sign it, or the original was lost. In the case of a long delayed certification (over 6 months), the provider or supplier may choose to submit with the delayed certification some other documentation (e.g., an order, progress notes, telephone contact, requests for certification or signed statement of a physician/NPP) indicating need for care and that the patient was under the care of a physician at the time of the treatment. Such documentation may be requested by the contractor for delayed certifications if it is required for review. It is not intended that needed therapy be stopped or denied when certification is delayed. The delayed certification of otherwise covered services should be accepted unless the contractor has reason to believe that there was no physician involved in the patient’s care, or treatment did not meet the patient’s need (and therefore, the certification was signed inappropriately). (Reference:  CMS Pub 100-02, Ch. 15, 220.1.3, D)

   Date Posted: 04/04/2007, Date Reviewed/Revised: 01/05/2008

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9. Does the progress report count as the re-certification if we obtain a physician signature?

   The format of all certifications and re-certifications and the method by which they are obtained is determined by the individual facility and/or practitioner. Acceptable documentation of certification may be, for example, a physician’s progress note, a physician/NPP order, or a plan of care that is signed and dated during the interval of treatment by a physician/NPP, and indicates the physician/NPP is aware that therapy service is or was in progress and the physician/NPP makes no record of disagreement with the plan when there is evidence the plan was sent (e.g., to the office) or is available in the record (e.g., of the institution that employs the physician/NPP) for the physician/NPP to review. (Reference:  CMS Pub 100-02, Ch. 15, 220.1.3, A)

   Date Posted: 04/04/2007, Date Reviewed/Revised: 01/05/2008

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10. Is there a trend or preference for more laymen vs. scientific terminology?

    Either. However, if scientific terminology is being used including abbreviations then they must be standard/accepted abbreviations.

    Date Posted: 04/04/2007, Date Reviewed/Revised: 01/09/2008

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11. If a patient is part of a physician group practice, can another physician from the group certify the plan of care in the absence of the referring physician?

    The plan of care requires certification by the referring physician per the Pub 100.2/Chapter 15. In addtion, when therapy services are continued for longer than 1 month, the physician/NPP who is responsible for the patient’s care at that time should review and certify the plan for each interval of therapy. It is not required that the same physician/NPP order, certify and/or recertify the plans.  This information is located in Publication 100-2 Chapter 15 at http://www.cms.hhs.gov/manuals/Downloads/bp102c15.pdf

    Date Posted: 04/04/2007, Date Reviewed/Revised: 01/09/2008

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12. Is electronic signature acceptable?

    Signature means a legible identifier of any type (e.g., hand written, electronic, or signature stamp). Policies in CMS IOM Pub. 100-08, Medicare Program Integrity Manual, chapter 3, §3.4.1.1 (B) concerning signatures apply.
    

    Date Posted: 04/04/2007, Date Reviewed/Revised: 01/05/2008

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